Refer a Patient to LaHaye Orthodontics

Thank you for trusting LaHaye Orthodontics with your patients. We value the relationships we have built with our dental colleagues throughout Thibodaux, Houma, and South Louisiana and appreciate the opportunity to work together in providing exceptional patient care.

To refer a patient, please complete the form below. Our team will contact the patient to schedule their orthodontic evaluation and will work closely with your office throughout their care when appropriate.

Practice Information

Bold Fields are required.

Doctor Name: First and Last Practice Name: Your Email Address:

Referral Information

Name of the Patient You are Referring: First and Last Patient's Phone Number: Patient's Email Address:

Radiographs Sent?

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When Were They Sent?

Comments:

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Submit Referral